Pilot error versus sociotechnical systems failure: a distributed situation awareness analysis of Air France 447. (2nd January 2016)

• Record Type: Journal Article
• Authors: Salmon, Paul M.; Walker, Guy H.; Stanton, Neville A.
• Is Part Of: Theoretical issues in ergonomics science. Volume 17:Number 1(2016)
• Page Start: 64
• Page End: 79
• Publication Date: 2016-01-02
• Subjects: Air France 447 -- distributed situation awareness -- aviation -- accident analysis; Human engineering -- Periodicals; Human engineering -- Research -- Periodicals; 620.82
• DOI: 10.1080/1463922X.2015.1106618
• Languages: English
• ISSNs: 1463-922X

Abstract

ABSTRACT: The Air France 447 crash occurred in 2009 when an Airbus A330 stalled and fell into the Atlantic Ocean, killing all on board. Following a major investigation, it was concluded that the incident resulted from a series of events that began when the autopilot disconnected after the aircraft's Pitot tubes froze in an adverse weather system. The findings place scrutiny on the aircrew's subsequent lack of awareness of what was going on and of what procedure was required, and their failure to control the aircraft. This article argues that this is inappropriate, instead offering a systems level view that can be used to demonstrate how systems, not individuals, lose situation awareness. This is demonstrated via a distributed situation awareness-based description of the events preceding the crash. The findings demonstrate that it was the sociotechnical system comprising aircrew, cockpit and aeroplane systems that lost situation awareness, rather than the aircrew alone.